him 2810 dicussion 16
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2810
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Health Science
Date
Dec 6, 2023
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docx
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Uploaded by DeaconMosquito1444
Physician queries play a crucial role in healthcare documentation and coding processes. These queries
serve as essential communication tools employed by clinical documentation specialists (CDS) or coders.
Their primary function is to seek clarification from physicians regarding any ambiguous, incomplete, or
conflicting information within medical records. The overarching goal is to ensure the accuracy and
comprehensiveness of coding, which is fundamental for proper reimbursement, quality reporting, and
overall patient care improvement.
In addressing data and coding discrepancies, physician queries act as a vital bridge between the
information documented in medical records and the coding requirements. When coders encounter
disparities or uncertainties during the review of documentation, they initiate queries to physicians,
seeking detailed explanations or additional information. This process serves multiple purposes, including
improving accuracy by eliminating ambiguities and ensuring that the assigned codes accurately
represent the patient's true medical condition. Additionally, physician queries play a significant role in
maintaining compliance with regulatory standards, as proper documentation and coding are essential for
adhering to coding and billing guidelines.
Beyond regulatory considerations, the impact of physician queries extends to patient care. The clarity
and precision achieved through the query process contribute to an enriched patient care experience by
providing healthcare providers with a comprehensive and accurate medical history. In essence, the
utilization of physician queries is not only a mechanism for administrative and regulatory adherence but
also a catalyst for elevating the quality and efficacy of patient care practices.
Example of a Physician Query: Subject: Query Regarding Patient Encounter - Case #123456
Dear Dr. Chase,
I hope this message finds you well. While reviewing the medical records for Patient John Doe (DOB:
05/12/1966), I noted some discrepancies that require your clarification to ensure accurate coding and
billing.
Specifically, in the progress notes dated 12/22/2023, there is a mention of "respiratory distress," but the
details regarding the severity and any associated conditions are not provided.
Could you kindly provide additional information regarding the severity of the respiratory distress and any
related diagnoses or conditions observed during this encounter?
Thank you for your attention to this matter.
Sincerely, XYZ [Medical Coder]
Sources:
American Health Information Management Association (AHIMA) - "Guidelines for Achieving a Compliant
Query Practice."
Centers for Medicare & Medicaid Services (CMS) - "ICD-10-CM Official Guidelines for Coding and
Reporting."
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